Canada / Netherlands Agreement Applying for a Netherlands Invalidity Benefit Here is some important information you need to consider when completing your application. Please ensure you sign the application. If your spouse’s or partner’s signature is requested on the application, make sure that you both sign the application. If you are signing with a mark, (for example: “X”) the signature of a witness is required. Your application must be supported by documentation. Please submit the documents requested. Failure to complete the application and provide the requested documentation may result in delays in processing your application. Where original documents are specifically requested, originals must be submitted with your application. You should keep a certified true copy of any originals you send us for your records. Some countries require original documentation which will not be returned to you. You may submit the original or a photocopy that is certified as true for any of the documents where originals are not required. It is better to send certified copies of documents rather than originals. If you choose to send original documents, send them by registered mail. We will return the original documents to you. We can only accept a photocopy of an original document if it is legible and if it is a certified true copy of the original. Our staff at any Service Canada centre will photocopy your documents and certify them free of charge. If you cannot visit a Service Canada Centre, you can ask one of the following people to certify your photocopy: Accountant; Chief of First Nations Band; Employee of a Service Canada Centre acting in an official capacity; Funeral Director; Justice of the Peace; Lawyer, Magistrate, Notary; Manager of Financial Institution; Medical and Health Practitioners: Chiropractor, Dentist, Doctor, Pharmacist, Psychologist, Nurse Practitioner, Registered Nurse; Member of Parliament or their staff; Member of Provincial Legislature or their staff; Minister of Religion; Municipal Clerk; Official of a federal government department or provincial government department, or one of its agencies; Official of an Embassy, Consulate or High Commission; Officials of a country with which Canada has a reciprocal social security agreement; Police Officer; Postmaster; Professional Engineer; Social Worker; Teacher. People who certify photocopies must compare the original document to the photocopy, state their official position or title, sign and print their name, give their telephone number and indicate the date they certified the document. They must also write the following statement on the photocopy: This photocopy is a true copy of the original document which has not been altered in any way. If a document has information on both sides, both sides must be copied and certified. You cannot certify photocopies of your own documents, and you cannot ask a relative to do it for you. Return your completed application, forms and supporting documents to: International Operations Service Canada Ottawa, Ontario K1A 0L4 CANADA Disclaimer: This application form has been developed by external sources in cooperation with Human Resources and Skills Development Canada. The content and language contained in the form respond to the legislative needs of those external sources. 1 CANML 204 1 Agreement on Social Security between Canada and the Kingdom of the Netherlands Accord d e securite sociale entre le Canada e t le Royaume des Pays-Bas Verdrag inzake sociale zekerheid tussen het Koninkrijk der Nederlanden en Canada Investigation of a claim for Dutch invalidity benefits 1 Instruction d'une demande de prestations d'invalidite des Pays-Bas Behandeling van een aanvraag o m Nederlandse invaliditeitsuitkering - - 1. Information concerning the claimant Renselgnements sur le requerant lnllchtlngen betreffende de aanvrager Canadian Social Insurance Number Numdro d'assurance sociale du Canada Canadees sociaal verzekeringsnummer Dutch registration number (if known) Numdro d' enregistrement aux Pap-Bas (s'il est connu) Nederlands reg~stratienummer(~nd~en bekend) Family name, Nom de famrlle Naam Family name at birth Nom de famille B la naissance Geboortenaam Given name($) Prdnom(s) Vooma(a)m(en) Date of birth Day/JoudDag MonthAUoisMaand Year/AnnBa/Jaar Date de naissance Geboortedatum Sex Sexe Geslacht Male EF'Iin Female (=foyin National Nat!onalg Nat~onal~teit Language Preference Langue prdfdrbe pour la correspondance Voorkeurstaal Marital Status Btat civil Burgerlljke staat - English Anglais Engels C] C] Sin le cbhtaire Ongehuwd - Home address Adresse du domlclle Hulsadres Street Rue Straat Postal Code Code Postal Postcode French Dutch Nderlandais Nederlands Married Marid@) Gehuwd Divorced Divot&(e) Gesche~den 0F P :; C] Se arated ~$arB(~ Gesche~en levend 3 Number Numdro Nummer E% Plaats Province Province Provincie Country Pays Land Telephone number Numdro de tdldphone Telefoonnurnmer Malllng address (if different from above) Admsse postale (sl diffbmnte de I'adresse du domlclle) Postadres (lngeval dlt afwijkt van hulsadres) Stre@ Number Rue NumBm Nummer Straat Postal Code Code Postal Postcode Telephone number Numdro de tdldphone Telefoonnurnmer Province Province Provincie %% Plaats Country Pays Land Livins to ether conjoint&) de faif Samenwonend 2. 1 became incapable of work on Je suis incapable de t~vaillerde uis le Ik ben arbeldsongesch~ktgewor&n op DaylJoudDag MonthlMoidMaand YearlAnnBelJaar - 3. On that day I was engaged in B celte date Op die dag was ik werkzaam paid employment 1' occupars un emploi remunere ln loond~enst 0jeself-employment travaillars a mon compte als zelfstandige 4. Occu ation 4 ~mppi Beroep 5 5. Gross annual earnings from paid employment Gains annuels bruts rovenant de I'emploi r6mun6r6 Bruto jaarinkomen uifarbeid in loondienst 6 6. Gross annual earnings from self-employment Gains annuels bruts rovenant de I'emploi autonome Bruto jaarinkomen uifalbeid als zelfstandige 7. The incapac for work Mon inc acr 6 de travail De arbe%ongeschiktheid ? has not been caused by a third party cause par un trers veroorzaakt door een derde pnitfs "'4 ' 8. Information concemin present occupational activities (if any). Rensergnementssur act~vitds r o f e ~ ~ ~ ~ n n actuelles elles Gegevens omtrent eventuele hui$e werkaamheden & After commencement of the incapacity for wo?<I did not fo!low occupational retraining courses rhs Qtredevenu(e) rncapable de travailler, je n'ar as survl de cours de recyclage professronnel. de aanvang van de arbeidsongeschiktheid heb iRgeen omschol~ngscursussen gevolgd. % After commencement of the incapacity for work l.followed retraining courses in: Aprhs Qtredevenu(e1 rncapable de travarller, i' ar surw des cours de recyclage professiorinel.dans le domaine suiant: Na de aanvang van de ale~dsongesch~kthe~d ben ik omgeschoold tot: 8 not engaged in o&upational activites. je ne tmvarlle as. verricht geen &eroepswerkzaamheden engaged in paid employment for occu e un emplor rdmun6r6 vernc # I ? t arbeld ln loond~enstop hours daily. heures par jour. uren per dag. en aged in self-employment for je hvallle B mon m m te verticht arbeld als ze%sndige op hours daily. heures par jour. uren ker gag. or Name of resent emplo er Nom de l!jm~loveur adwl Naam van hiridbe werkgever --.A Address Adresse Adres ,, + T pe of work presently pursued d t u r e du travqll Aard van de huldige werkaamheden Date of commencement of work presently pursued Date d'entrbe en fonction Aanvangsdatum van de huidige werkzaamheden Earnings from work present1 pursued Gains provenant de /'emp1o?actuel lnkomen utt de huldige werkzaamheden Q DaylJoudDag MonthlMoislMaand YearlAnnMJaar weekly par semaine per week monthly Par mo1.s per maand 9. Information relating to the claimant's residence and work history. 10 Renseignements sur les lieux de rbsidence et les anttkbdents professionnels du requerant. Gegevens omtrent woontijdvakken, tijdvakken van volgen van een opleiding en het arbeidsverleden van aanvrager. Type of period 11 City and country of residence City and country of employment Ville e! pays de rbsrdence Ville et pays de Organisme travail d'assurance soclale Plaats van Soclaal aheid en verzekerings werkland -orgaan Woonplaats en woonland 10. Information concemin claimant's household Renseignements sur menage du requBrant Gegevens omtrent het hu~shoudenvan aanvrager k Social insurance institution 12 Social lnsurance number Numbro d'assurance sociale Sociaal verzekeringsnummer Type 13 %:urance Aard 14 living alone vis seul(e) ben alleenstaande maintaining a common household with: partage un menage avec: voer een gemeenschappelijk huishouden met: Family name Nom de familie Naam Given name(s) PrBnom(s) Vooma(a)m(en) Date of birth DaylJoudDag MonthlMoislMaand YearlAnnBdJaar Date de naissance Geboortedatum 'The above mentioned La penonne susmentionnde Bovengenoemde is not pursuing an occupational activ'i n'occupe pas d'emploi v e r M geen beroepswellaaamheden cnkqpe uri emploi ' vemcht bemepswerkzaarnheden Annual gross amount of earnin s from the occupational activity. Gain? annueis brut provenant 618 I'ernploi. Brutojaarbedrag van de lnkomsten uit beroepswerkzaamheden Children belonging to my household: Enfants appatienant au menage; Tot het hu~shoudenbehorende k~nderen: Given name(s) Family name Norn de famille Prenorn(s) 1 Voorna(a)rn(en Naam Date of birth Relationship Dale de nalssance Liens 15 Geboortedatum Verwantschap 1 Attending schOO Aux etudes I Schoolgaand Occupation Ernploi Beroep I, the claimant, hereby apply for invalidity benefits and a supplementary allowance under Dutch law (aawlwao and tw) I completed thls appl~cat~on form as completely as possible and declare that the given information is true. Par la prbsente, je demande d recevoir des prestations d'invalidit6 et une allocation suppl&mentaireen vertu de la loi neetfandaise aaw/wao et hv). J'ai rempli le ormulaire avec le plus de precision possible et je certifie que les renseignements que j'ai foumis sont v8ridlques. / Hjermede doe ik een aanvraag voor aawlwao-uitkering en een toesla ingevol e de "Toeslagenwet". Dlt aanvraagformul~erIS door ml] zo volled~gmogelijk en naar waarhel%ingevul%. I hereby authorize the Canadian competent institution to disclose Informationcontained in their records to the competent Dutch institution for the purpose of determining whether I am eligible for a Dutch invalidity benefit. Par la resente, autorise lUtablissement canadien competent d divul uer les renseignements contenus dans leurs dossiers A l u t a i s s e m e n n e a n d a i s competent pui dBtetminera siie suis adkissible aux prestations Ginvalidit6 des Pays-Bar Hiehij machti ik de bovengencl-emdeCanadese instellin om de informatie waarover dit orgaan beschikt toe te zenden aan de bevpt! de 8ederiandse ~nstellingopdat deze instellingkn beoordelen of ik in aanmeting kom voor een Nederlandse lnvalldltel8ultkenng. Signature S~gnature Handtekening Date Date Datum I have, in accordance with Article 5 par. 3 of the administrative arrangement, verified the information given by the claimant. En vertu du paragraphe 3 de I'article 5 de I'arrangement administratif, j'ai v6rifi6 les renseignements foumis par le requ6ranf. Ik heb de door de aanvrager verstrekte informatie overeenkomstig artikel5, lid 3 van het administratief akkoord geverifieerd. International Operations Division Income Securlty Programs Human Recources Development Canada Ottawa, Ontario K I A 0L4 Stamp and signature Cachet et si nature Stempel en fandtekening Date Date Datum - - Notes Notes Noten 1. This application form is to be used for claming Dutch invalidity benefits and supplementary allowances under the Canadian-Dutch agreement on social security. It is an offence under Dutch law to make a fblse or misleading statement on this application. Ce formulaire serf a demander des prestations d'invalidite et des allocations supplementaires des Pays-Bas en veflu de I'accord de secun'te sociale Btabli entre le Canada et Ies Pays-Bas. Toute dklaration fausse ou trompeuse faite dans la presente demande constitue un delit aux termes de k l o i n&rlandalse. Dit formulier dient gebruiM te worden voor het met toepassing van het Nederlands - Canadees verdrag inzake de sociale zekerheid aanvragen van een Nederlandse invaliditeitsuitkering op grond van de aaw enlof wao en een toeslag ingevolge de Toeslagenwet. Volgens Nederlands recht pleegt u een misdrijf indien u op deze aanvraag valse of mlsleldende verklarlngen af legt. 2. Please indicate the language in which you wish to receive your correspondence. Please note that the official decision on your application for invalidity benefits and supplementary allowances must be issued in the Dutch language. You will however receive a summary of that decision in the language you requested. Veuillez prbciser dans quelle langue vous aimeriez recevoir votre correspondance. La dbcision offidelle relative B votre demande de prestations d'invaliditd et d'allocations supplbmentaires doit &re dmise en nderlandais, mais vous en recevrez un rbsumd dans la langue que vous aurez choisie. Gelieve aan te geven in welke taal u de correspondentie wilt ontvangen. Wij maken u er op attent dat de officiele beslissing op uw aanvraag om Nederlandse uitkeringen in het Nederlands gesteld moet zijn. Bij die beslissing ontvangt u een uhtreksel in uw voorkeurstaal. 3. For verification purposes you must provide an official document indicating your home address. Aux fins de vdrlfication, veuillez foumlr on document officlel oh figore votre adresse actuelle. In verband met de verificatie moet u een officieel document overleggen, waarop uw huisadres vermeld is. 4. Please indicate your occupation as precisely as possible. Veuillez indiquer la nature de votre emploi avec le plus de precision possible. Vermeld uw beroep zo nauwkeurig mogelijk. 5. For verification purposes you must provide your pay-slips covering 12 months preceding the date of commencement of your incapacity for work. Aux fins de vbrification, vous devez foumir les talons de paye des douze mois qui prbcddent la date du dbbut de votre incapacitb de travail. In verband met de verificatie moet u uw loonstroken over de 12 maanden voorafgaande aan het intreden van uw arbeidsongeschiktheid overieggen. 6. For verification purposes you must provide your notice of assessment from "Reveneu Canada Taxation" covering the 12 months preceding the date of commencement of your incapacity for work. Aux fins de vbrifcation, vous devez foumir I'avis de cotisation de Revenu Canada - lmpbt pour les douze mois qui pkt3dent la date du ddbut de votre incapacite de travail. In verband met de verificatie moet u het aanslagbiljet van "Revenue Canada Taxationnover de 12 maanden voorafgaande aan het intreden van uw arbeidsongeschiktheidoverieggen. 7. When your incapacity for work has been caused by a thlrd party you.must attach full details, including the name and address of that third party. These details should be provided on a separate sheet of paper. Si votre lncapacite de travail a BtB caude par un tiers, vous devez donner des details sur la situation, notamment le nom et I'adresse du tiers. Ces renseignementsdoivent Btre p&sent& sur one autre feuille. lndien de arbeldsongeschlktheidveroorzaakt is door een derde, dient u in een bijlage een volledige beschrijving aan te geven inclusief de naam en het adres van die derde. 8. Please provide detalls. Veulllez donner des pddslons B ce sujet. Gelieve nadere bgzonderheden aan te geven. 9. For verification purposes you must provide your most recent pay-slips or Notice of Assessment from Revenue Canada Taxation. Aux fins de vdrification, vous devez foumir les talons de paye ou I'avis de cotisation de Revenu Canada - Imp& les plus rkents. In verband met de verificatie moet u de laatst ontvangen loonstroken of belastingforrnulieren overleggen. 10. Please provide in chronological order a full description of all periods of residence or employment since the age of 18. In the case of periods of school attendance or vocational training you must specify the type of schooling or training and the diplomas received. Veuillez faire une description chronologique detaillee des lieux ou vous avez habite et des emplois que vous avez eus depuis I' i g e de 18 ans. Si vous etiez aux etudes ou en formation pendant un certain temps, precise2 la nature de vos etudes ou de votre formation et les dipl6mes que vous avez reps. U dient een chronologisch overzicht te geven van alle tijdvakken van wonen of werken vanaf het bereiken van de 18jarige leeftijd. Bij school- en beroepsopleidingen dient u de aard van de opleidingen en de behaalde diploma's aan te geven. 11. Please indicate if the period in question was a period of residence, period of employment or a period of schooling. Veuillez prkciser s'il s'agit dune periode de rdsidence, d'emploi ou dUtudes. Gelieve het type tijdvak aan te geven; woontijdvak, arbeidstijdvak, tijdvak waarin een opleiding gevolgd is. 12. Please provide the name and the address of the social security institution. Veuillez donner le nom et I'adresse de I'oganisme de sdcurit6 sociale. Gelieve volledige informatie te verstrekken omtrent naam en adres van het sociaal verzekeringsorgaan. 13 Please indicate the type of insurance: A = compulsory, B = voluntary. Veuillez prdciser le type d'assurance :A = assurance obligatoire, B = assurance facultative. Gelieve de soort verzekering aan te geven: A = verplicht, B = vrijwillig. 14. This information is necessary to determine your possible entitlement to supplementary allowances according to the "Toeslagenwet" and to determine your tax group. If you do not provide this information you will not be entitled to supplementary allowances and you will be classifed in the highest tax group. Cette section aidera les autorit6s compdtentes d dhcider si vous avez droit aux allocations suppldmentaires en vertu du Toeslagenwet' et A d6terminer d quel groupe vous appartenez sur le plan fiscal. Si vous ne la remplissez pas, vous n'aurez pas droit aux allocations suppl6mentaires et vous serez class6 dans le groupe le plus imposd. Deze informatie is noodzakelijk in verband met de toeslagenwet en belastingheffing. lndien u deze informatie niet verstrekt heeft u geen recht op een toeslag ingevolge de toeslagenwet en wordt u in de hoogste belastinggroep , ingedeeld. 15 1 = natural child, 2 = legally adopted child, 3 =foster child. 1 = enfant naturel, 2 = enfant adopt6 16galement, 3 = enfant plad. 1 = eigen kind, 2 = geadopteerd kind, 3 = pleegkind. Canada / Netherlands Agreement Documents and/or information required to support your application [CAN/NL 204] for a Netherlands Invalidity Benefit Complete the attached forms: CAN/NL 216 completed by your employer Medical Report [ISP 2519], Questionnaire for Disability Benefits [ISP 2507] and Authorization to Disclose Information/Consent for Medical Evaluation [ISP 2502] if you have never applied for a Canada Pension Plan Disability benefit Original or certified documents to be submitted for you and your partner or the person living with you: Birth certificate Marriage certificate (if applicable) Proof of nationality Valid photo identification document such as a current passport, driver’s license, government issued ID card, etc. Original or certified documents to be submitted for you: Proof of your home address (verified from an official document) Bank account details Proof of your employment during the last 12 months prior to becoming incapacitated for work (such as: pay slips, Notice of Assessment from the Canada Revenue Agency, etc.) IMPORTANT: If you have already submitted any of the documents required when you applied for a Canada Pension Plan or Old Age Security benefit, you do not need to resubmit them. This form is to assist the GAK in order to calculate the amount of Dutch invalidity benefit. Ce formulaire a pour but d'aider le GAK a calculer le montant de la prestation d'invalidite des Pays-Bas. 1. Name Nom Date of birth Date de naissance 2. Indicate the em loyee's salary (includin all bonuses, commissions etc.) for the 12 month period immediahly preceding the date work cessation resulting from mcapacily lndi uez la salaire de I'em loyd ( com ris toutes les rimes, les commissions, etc.) pour la pjriode de 12 mois py&ddanfimm&iatement la &te OIIiremployb a cessd de travailler en raison d'une incapacrtd. 8 3. During the above-mentioned peood the employee worked: Au cours de la pdnode susmentronnde, I'employd a travarlld: from de I specify dates) pdcisez les dates) to A type of occupation genre d'emploi the gross amount of monthly wages for the month work cessation (excluding emoluments such as overtime indiquez le montant brut du salaire mensuel pour le mob pdcddant immddiatment la cessation d'emploi 2r I'exclusion des dmoluments, comme par exemple la rdmundration des heures suppl menfaires ou les indemnitds de vacances): Q b. In case of variable wa es: indicate the ross amount of wages for the 12 month period above-mentioned (excyudin emolumenes such as overtime payholiday allowance): En cas de traitement variabye: indiquez le montant brut du salaire pour la pdn'ode de 12 mois susmentionnde (A I'exclusion des dmoluments, comme par exemple la rdmundration des heures suppldmentaires ou les indemnitds de vacances): 5. The person concerned use to work La personne en question travaillait hours per week heures par semaine full-time B temps plein part-time B temps partiel 6. During the above-mentioned 12 month period, the following amounts were paid: Au cours de la pdriode susmentionnde de 12 mois, les montants suivants ont dtd versds: Holiday allowance lndemnitd de vacances Christmas bonus Prime de Noel Overtime Temps suppldmentaire Number of hours of overtime Nombre d'heures suppldmentaire Other (specify) Autres (prdcrsez) 7 Period for which no salary was paid to the person concerned: from Pdriode pendant laguelle aucun salaire n'a dtd verse d la de personne en questron: from de to from de to 8 Gratifications/bonuses/profit sharings received over the last B to d B three ears prior to the ~ncapacityfor work: 19 -= ~rati&ations/~rime articipalion ~ aux bedndfices reper au cours des trors,dernr&es anndes avant quq Ikmployd ne cesse de travarller en rarson d'une Incapacrtd: 19 -- description 19 -- description description 9. Had the employee contined working, what would the estimated amount of wages have been 12 months following the actual cessation of employment? Si cet employe avait,continue a travailler, quel aurait-8te le montant approximatlf de son salaire 12 mols apres la cessation reele de I'emploi? 10. Indicate the date on which Canada Pension Plan contributions were last made: lndi uez la date 2r laquelle I'emplo 6 a verse des cotisations au h g r m e de pensions du c a n a d pour la demlhre fo~s: Name and address of em loyer Nom et adresse de I'empkyeur Date Date Authorized si nature Signature deya personne autorisde Human Resources Development Canada Développement des ressources humaines Canada Personal Information Bank HRDC PPU 140 Fichier de renseignements personnels DRHC PPU 140 Protected When Completed - B Protégé une fois rempli - B MEDICAL REPORT - RAPPORT MÉDICAL SECTION A To be completed by Applicant - Doit être remplie par le demandeur First Name - Prénom Initial - Initiale Last Name - Nom de famille Home Address (No., Street, Apt., or R.R.) Adresse du domicile (numéro, rue, app., ou route rurale) Postal Code Code postal City - Ville Date of Birth Date de naissance Telephone No. - N° de téléphone Y/A ( ) Province or Territory Province ou territoire M Social Insurance Number Numéro d'assurance sociale D/J - SECTION B To be completed by Physician - Doit être remplie par le médecin Please provide factual objective opinions - Veuillez donner une opinion factuelle objective 1 Height - Taille 2 a) How long have you known the patient? Depuis quand connaissezvous le patient? Weight - Poids b) When did you start treating the patient for the main medical condition? Quand avez-vous commencé à traiter le patient pour son état pathologique principal? Y/A M 3 Diagnosis (es) - Diagnostic(s) : 4 Relevant/significant medical history relating to the main medical condition: Antécédents médicaux pertinents/importants reliés à l'état pathologique principal : ISP-2519-00 Internet Version Please write legibly - Veuillez écrire lisiblement Page 1 of/de 4 c) Date of last visit Date de la dernière visite Y/A M D/J Social Insurance Number Numéro d'assurance sociale 5 Over the past two years, has the patient been admitted to a hospital/institution? Au cours des deux dernières années, le patient a-t-il été admis à l'hôpital ou dans une institution? Yes Oui If yes, please list: Dans l'affirmative, veuillez indiquer : No Non Name of the Hospital(s)/Institution(s) - Nom de(s) l'hôpital(aux) ou de(s) l'institution (institutions) The date(s) of admission La (les) date(s) d'admission Y/A M The reason(s) for admission La (les) raison(s) de l'admission D/J 6A Is there supporting evidence for the main medical condition? Please attach supporting documentation. Y a-t-il des preuves à l'appui de l'état pathologique principal du patient? Veuillez joindre les documents à l'appui. Laboratory Reports Rapports de laboratoire Yes Oui No Non X-ray reports Radiographies Yes Oui No Non Consultants' opinions Opinions de consultants Yes Oui No Non Other Autre Yes Oui No Non Documentation to be returned Documents devant être retournés Yes Oui No Non 6B Please describe relevant physical findings and functional limitations. Veuillez décrire les observations physiques et les limitations fonctionnelles pertinentes. Please write legibly - Veuillez écrire lisiblement Page 2 of/de 4 Social Insurance Number Numéro d'assurance sociale 7 Are further consultations or medical investigations planned relating to the main medical condition? Prévoyez-vous effectuer d'autres consultations ou évaluations médicales en rapport avec son état pathologique principal? Yes Oui If yes, please specify: Dans l'affirmative, veuillez préciser : No Non 8 Is the patient currently on medication(s) as a result of the main medical condition? Le patient prend-il présentement des médicaments en raison de son état pathologique principal? Yes Oui If yes, please indicate dosage and frequency. Dans l'affirmative, veuillez indiquer la dose et la fréquence. No Non 9 Treatment: List type and response. Traitement : Indiquez le genre et la réaction. Please write legibly - Veuillez écrire lisiblement Page 3 of/de 4 Social Insurance Number Numéro d'assurance sociale FOR OFFICE USE ONLY - À L'USAGE EXCLUSIF DU BUREAU A.C. - C.V. Y/A Initials - Initiales M 10 Prognosis of the main medical condition of this patient - Pronostic au sujet de l'état pathologique principal du patient : 11 Additional Information - Renseignements supplémentaires SIGNATURE (Please print or use a stamp - Veuillez écrire en lettres moulées ou estampiller) Physician's Full Name - Nom du médecin au complet Address - Adresse Family Physician Médecin de famille Specialty Spécialité Postal Code Code postal Signature Y/A M X D/J Telephone No. - N° de téléphone ( Please write legibly - Veuillez écrire lisiblement Page 4 of/de 4 ) - D/J Human Resources Development Canada Personal Information Bank HRDC PPU 140 Développement des ressources humaines Canada Protected When Completed - B QUESTIONNAIRE FOR DISABILITY BENEFITS CANADA PENSION PLAN 1 FIRST NAME AND INITIAL LAST NAME SOCIAL INSURANCE NUMBER EDUCATION 2 What was the highest grade you Have you attended college or university? completed in school? Yes If yes, indicate number of years and/or diploma/degree obtained. No 3 Have you ever been involved in any technical, trade, or on the job training? Dates Yes If yes, provide the following details: No Type of program Certificate obtained WORK HISTORY (BE SURE TO INCLUDE WORK DONE IN CANADA AND/OR OTHER COUNTRIES) EMPLOYEE 4 Have you stopped working completely? Type of Work Yes, go to question 5. No, provide the following information: Number of hours per day Full-time Part-time Number of days If seasonal, explain period(s) of work. per week 5 If you have stopped working completely, Volunteer Seasonal Salary per hour /or per day /or per year What kind of work did you do in your most recent job? provide the following information: Date employment started Why did you stop working? Year Month Last day on the job Day Year b) When did you actually stop working in the business? Year Month Day 6 Name and full address of your present or most recent employer. SELF - EMPLOYED 7 If you are or were self-employed, provide the following information: a) Date business started Year Month Day c) Why did you stop working in the business? d) Describe the business operation. e) What was your involvement with the business? ISP-2507-00E Internet Version Ce formulaire est disponible en français - ISP-2507F Page 1 of 7 Month Day Social Insurance Number SELF - EMPLOYED (CONTINUED) f) Are you involved in the business in any way at the present time? Yes, explain your present involvement. No, provide the following information: Indicate what disposition has been made for the business: sold rented Year Month Day Date of disposition profit sharing If no disposition has been made of the business, how does it operate now and what arrangements are you contemplating in the future? g) What was the last year that an income tax return on the operation of the business was filed in your name? h) Will you declare yourself a self-employed person for income tax purposes this year? Yes No OTHER WORK HISTORY IF THERE IS INSUFFICIENT SPACE TO LIST ALL YOUR OTHER TYPES OF WORK, USE THE SPACE AT THE END OF THIS QUESTIONNAIRE. 8 In the past two years, did you do any other work in addition to your Yes main job (such as part-time farming, night or other employment)? No Type of work Number of hours Number of hours per day per week If yes, provide the following details: Last day on the job Work started Year Month Day Year Month Day Name and full address of employer From 9 Have you done any other type of work in the last five years? Year Yes If yes, list the type of work and the dates. Month To Day Year Month Day No 10 Because of your medical condition, did you have to do a lighter job or a different type of work? Yes If yes, please describe. No 11 Yes If yes, give the date: Has your physician told you when you can return to work? 12 Yes Do you plan to return to work or seek work in the near future? a) The date you plan to return to your former employer/employment. Year Month b) The date you will start a new job. Page 2 of 7 Year Month No If yes, answer one of the following questions: No Year Month c) The date you plan to start looking for work. Year Month Social Insurance Number OTHER BENEFITS 13 If you are receiving any form of accident or illness/disability benefits, state the name of the insurance company. 14 If any of your health problems are covered by Provincial workers' compensation benefits, provide details in each case. Claim Number Province or Territory Year Injury State type of benefit you now receive. Percentage of pension awarded 15 Have you received regular Employment Insurance benefits in the last two years? Yes Year Month If yes, give the dates: Year Month Day Year Month Day Year Month Day To Year Month From No Day From Day To MEDICAL INFORMATION 16 When could you no longer work because of your medical condition? 17 Height Weight Right-handed Left-handed 18 State the illnesses or impairments that prevent you from working. If you do not know the medical names, describe in your own words. 19 Describe how these illnesses or impairments prevent you from working. 20 If you have other health-related conditions or impairments, please describe them. 21 If you had to stop other activities (such as hobbies, sports or volunteer work), please explain and give dates activities ceased. Page 3 of 7 Social Insurance Number 22 Explain any difficulties/functional limitations you have with the following: Sitting/Standing (How long?) Seeing/Hearing Walking (How long and how far?) Speaking Lifting/Carrying (How much and how far?) Remembering Reaching Concentrating Bending (How much?) Sleeping Personal needs (Eating, washing hair, dressing, etc.) Breathing Bowel and bladder habits Driving a car (How long?) Household maintenance (Cooking, cleaning, shopping and similar activities) Using public transportation Page 4 of 7 Social Insurance Number INFORMATION ABOUT YOUR PHYSICIANS 23 Provide the following information about the physician who will be completing your medical report. Physician's Full Name Specialist (Please specify) Family Physician City Address Province or Territory Country (If other than Canada) Year Postal Code Telephone Number Month Year When did you first see this physician? Month When was your last visit? What were the reasons for your visits? 24 List all other physicians you have seen in the last two years (space for two physicians is provided). If there is insufficient space to list all of your physicians, use the space at the end of this questionnaire. a) Physician's Full Name Specialty Address Province or Territory City Country (If other than Canada) Postal Code Telephone Number ( Year ) - Month Year Month Year Month When was your last visit? When did you first see this physician? Were your visits related to your present medical condition? Yes If yes, explain the reasons for your visits. No b) Physician's Full Name Specialty Address Province or Territory City Country (If other than Canada) Postal Code Telephone Number ( Year ) - Month When did you first see this physician? When was your last visit? Were your visits related to your present medical condition? Yes No Page 5 of 7 If yes, explain the reasons for your visits. Social Insurance Number HOSPITALIZATION 25 If you have been admitted to hospital in the last two years, please provide the following information. Space for two hospitals is provided. If there is insufficient space to list all of the hospitals, use the space at the end of this questionnaire. a) Name of hospital Mailing address (No., Street, Apt., P.O. Box, R.R.) City Province or Territory Year Month Day Country (If other than Canada) Year Month Date discharged Date admitted Postal Code Day Name of attending physician Reason for admission and type of treatment b) Name of hospital Mailing address (No., Street, Apt., P.O. Box, R.R.) City Province or Territory Year Month Day Date admitted Country (If other than Canada) Year Month Date discharged Postal Code Day Name of attending physician Reason for admission and type of treatment MEDICATION AND TREATMENT 26 List any medication you now take. Name of medication Dosage How often 27 Describe other treatment you receive (such as counselling, physiotherapy). 28 If future treatments or medical tests are planned, please explain, giving dates. 29 List any medical devices you use (such as crutches, cane, artificial limb, splints, braces, wheelchair, hearing aid, heart pacemaker, ostomy apparatus). Page 6 of 7 Social Insurance Number VOCATIONAL REHABILITATION (SEE GUIDE ON PAGE 9) 29 If considered suitable, would you consent to a vocational rehabilitation assessment? 30 Are you presently or have you ever been involved in a rehabilitation program? Yes No If no, please explain. Yes If yes, please provide details. No DECLARATION AND SIGNATURE I understand that it is an offence to make a false or misleading statement in an application for benefits. I realize that my personal information is governed by the Privacy Act and it can be disclosed where authorized under the Canada Pension Plan. I agree to notify the Canada Pension Plan of any changes that may affect my eligibility for benefits. This includes: an improvement in my medical condition; a return to work (full, part-time, volunteer, or trial period); attendance at school or university; trade or technical training; or any rehabilitation. Signature of Applicant or Representative Year Month Day X Telephone Number ( Use this space if required. Identify the number of the question the information belongs to. Page 7 of 7 ) - Human Resources Development Canada Développement des ressources humaines Canada Protected When Completed - A Personal Information Bank HRDC PPU 140 AUTHORIZATION TO DISCLOSE INFORMATION/ CONSENT FOR MEDICAL EVALUATION Last Name First Name and Initial Social Insurance Number City Home Address (No., Street, Apt., or R.R.) Province or Territory Country (If other than Canada) Postal Code Telephone Number ( ) - • I hereby authorize any physician, medical specialist, hospital, medical or vocational agency, financial institution, employer, educational institution, as well as any federal, provincial or municipal government department and agency, provincial social services and workers compensation board or administrator of private insurance plans, to disclose information contained in their records to Human Resources Development Canada, for the purpose of determining whether I am or continue to be disabled and whether any amount shall be paid or shall continue to be paid as a benefit under the terms of the Canada Pension Plan. • For the purpose of providing further medical evidence for the evaluation of my disability, I agree, upon request by the Canada Pension Plan Administration, to be examined by a qualified physician or a medical consultant specialist and to submit to such diagnostic tests as the physician or specialist may deem necessary. I also authorize the Canada Pension Plan Administration to provide any relevant medical information relating to my disability to the examining physician or a medical consultant specialist for the purposes of such examination. • Any personal information received by the Canada Pension Plan is protected under the Canada Pension Plan and the Privacy Act. I have the right to request access to this personal information and am aware that the information may be used or disclosed within the conditions imposed by the Canada Pension Plan and the Privacy Act and outlined in the Personal Information Bank HRDC PPU 140. • I have read the above statements. I understand that this information is essential to determine that I have or continue to have a severe and prolonged mental or physical disability. In addition, this information will be used to determine the date my disability began and ceased under the terms of the Canada Pension Plan. Should I choose not to consent to the disclosure of information and/or not to undergo a medical evaluation, I understand that a decision to grant or deny a disability benefit will be based upon the available evidence in my file. TO BE COMPLETED BY THE APPLICANT Signature of Applicant Year Month Day X TO BE COMPLETED BY A WITNESS IF SIGNED WITH A MARK "X" OR BY A REPRESENTATIVE OF THE APPLICANT If signed by a representative, consent is made on behalf of the applicant. First Name Last Name Telephone Number ( ) - Signature of Witness or Representative Year Month Day X This authorization form shall be valid for 2 years from the date of signature unless previously revoked in writing by the applicant or the representative signing this form. Any photographic or facsimile copy shall be as valid as the original. DISPONIBLE EN FRANÇAIS - ISP 2502 F ISP-2502-01-04 E Internet Version
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